Coping with voice prosthesis leakage during COVID- 19 pandemic

The corona (COVID-19) pandemic presents many challenges for laryngectomees and their medical providers. Because of the reduction or decrease in outpatient services and voice prosthesis availability, those using tracheoesophageal speech may have trouble in having their clinician-changed (indwelling) prosthesis replaced because of leakage through or around the prosthesis. A patient with a leak around or through the voice prosthesis is at an increased risk of aspiration with potential sequelae including pneumonia, which could lead to devastating outcomes if patients contract COVID-19.

Enclosed are suggestions how to cope with these challenges:

• If possible, switching to using patient-changed voice prosthesis (non indwelling)
• Extending the life span of the current voice prosthesis by keeping it clean using a cleaning brush and flushing bulb and preventing buildup of candida biofilm (see below).

If voice prosthesis leakage occurs:

• Attempting to stop the leak by cleaning and brushing it as suggested in The Laryngectomee Guide (pages 75-19 ) or at http://dribrook.blogspot.com/p/tracheo-esophageal-voice-prosthesis-tep.html 
• Stopping the leak by inserting an adequate plug (see picture below) into the prosthesis whenever consuming fluids or leaving it permanently and switching to alternate speaking method (e.g., esophageal speech, electrolarynx)
• Consuming viscous fluids that generally do not leak (i.e., yogurt, jelly, soup, oatmeal, etc) through or around the prosthesis 
• Drinking small amount of fluid without strong effort while lying down, swallowing the liquid as if it is a food item, speaking a few words each time fluids are swallowed, can reduce or  prevent the liquids from leaking into the trachea  

If the prosthesis has been accidentally removed or dislodged (not aspirated), a 12 Fr/ 16’’red rubber catheter (see picture below) or puncture dilator can be inserted into the trachea-esophageal puncture to prevent its closure until the voice prosthesis is replaced. An advantage to using a rubber catheter is that the red rubber catheter can serve as alternate means of nutrition until prosthesis replacement is possible.

The laryngectomee should seek immediate medical care if aspiration of the dislodged voice prosthesis has occurred as this may requires urgent intervention to remove it.

It is helpful to contact one’s speech and language pathologist and/or physician for guidance and when voice prosthesis leakage occurs.

More information how to prevent and deal with voice prosthesis leakage can be found in the sections below.
Information is also available in The Laryngectomee Guide http://goo.gl/z8RxEt and My Voice website at  http://dribrook.blogspot.com/p/tracheo-esophageal-voice-prosthesis-tep.html

Click to watch a video that explains what to do if the voice prosthesis leaks.

Voice prosthesis plugs

Red Catheter

Cleaning the voice prosthesis and preventing leaking

It is very important to keep the voice prosthesis clean to insure its proper function and durability. When not cleaned properly the prosthesis can leak, and the ability to speak can be compromised or weakened. It is recommended that the inner space (lumen) of the voice prosthesis be cleaned at least twice a day (morning and evening), and preferably after eating because this is the time when food and mucus can become trapped. Sometimes mucus blocks the prosthesis (when getting up in the morning or after eating) which interfere with the ability to speak. Cleaning is especially helpful after eating sticky foods or whenever one’s voice is weak.

The valve of a newly installed voice prosthesis may initially be stuck. The SLP can lubricate the valve with a small amount of olive oil, using the cleaning brush. This is done with great caution to prevent aspiration of the oil.

A prosthesis cleaning brush and flushing bulb are used in cleaning the prosthesis. 

                                               



Maintenance and prevention of leakage guidelines are:

1. Before using the brush provided by the manufacturer, dip it in a cup of hot water and leave it there for a few seconds. 
2. Insert the brush into the prosthesis (not too deep) and twist it around a few times to clean the inside of the device. 
3. Take the brush out and rinse it with hot water and repeat the process 2-3 times until no material is brought out by the brush. Because the brush is dipped in hot water one should be careful not to insert it beyond the voice prosthesis inner valve to avoid traumatizing the esophagus with excessive heat.
4. Flush the voice prosthesis twice using the bulb provided by the manufacturer using warm (not hot!) potable water. To avoid damage to the esophagus sip the water first to make sure that the water temperature is not too high.
5. Prevent formation of biofilm by yeast and bacteria (see below)

Warm water works better than room temperature water in cleansing the prosthesis probably because it dissolves the dry secretions and mucus and perhaps even flushes away (or even kills) some of the yeast colonies that had formed on the prosthesis.

Initially the mucus around the prosthesis should be cleaned using tweezers preferably with rounded tips. Following that the manufacturer-provided brush should be inserted into the prosthesis and twisted back and forth. The brush should be thoroughly washed with warm water after each cleaning. The prosthesis is then flushed twice with warm (not hot) water using the manufacturer’s provided bulb.

The flushing bulb should be introduced into the prosthesis opening while applying slight pressure to completely seal off the opening. The angle that one should place the tip of the bulb varies between individuals. (The SLP can provide instructions how to choose the best angle.) Flushing the prosthesis should be done gently because using too much pressure can lead to splashing of water into the trachea. If flushing with water is problematic, the flush can also be used with air.

The manufacturers of each voice prosthesis brush and flushing bulb provide directions of how to clean them and when they should be discarded. The brush should be replaced when its threads become bent or worn out.

The prosthesis brush and flushing bulb should be cleaned with hot water, when possible, and soap and dried with a towel after every use. One way to keep them clean is to place them on a clean towel and expose them to sunlight for a few hours, on a daily basis. This takes advantage of the antibacterial power of the sun’s ultraviolet light to reduce the number of bacteria and fungi.

Placing 2-3 cc of sterile saline in the trachea at least twice a day (and more if the air is dry), wearing an HME 24/7 and using a humidifier can keep the mucus moist and reduce the clogging of the voice prosthesis.

A voice prosthesis cleaning brush (Atos Medical )

A voice prosthesis flushing bulb (Atos Medical)

A sterile saline vial for respiratory tract use ("Saline bullet")

Preventing biofilm of yeast and bacteria from growing on the voice prosthesis

Overgrowth of yeast and bacteria in the form of a biofilm ( a thin, slimy film of microorganisms that adheres to a surface) on the voice prosthesis is one cause of the prosthesis leaking and thus failing. Nevertheless, it takes some time for yeast and bacteria to grow in a newly installed voice prosthesis and form the biofilm  that prevent its valve’s from closing completely. Accordingly, failures immediately after voice prosthesis installation are unlikely due to yeast growth. Formulation of biofilm on the valve may also lead to increased air flow resistance making it harder to speak.

The presence of yeast should be established by the person who changes the failing voice prosthesis  This can be done by observing the typical yeast (Candida) colonies that prevent the valve from closing and, if possible, by sending a specimen from the voice prosthesis for fungal culture.

The antifungal agents Mycostatin and Clotrimazole (Mycelex) troches, can be used to prevent voice prosthesis failure due to yeast. They are available with a prescription in the form of a suspension or tablets ( Mycostain) and troches (Mycelex.) Mycostatin tablets can be crushed and dissolved in water. There is anecdotal information that apple cider vinegar that is known to inhibit candida growth can be used to gargle and be swallowed to prevent yeast growth on the TEP.

Automatically administering anti-fungal therapy (i.e., mycostatin) just because one assumes that yeast is the cause of voice prosthesis failure may be inappropriate without proof. It is expensive, may lead to the yeast developing resistance to the agent, and may cause unnecessary side effects. 

There are, however, exceptions to this rule. These include the administration of preventive anti-fungal agents to diabetics; those receiving antibiotics; chemotherapy or steroid; and those where colonization with yeast is evident (coated tongue etc.).

Some advocate the insertion of small amount of antibiotics inside the voice prosthesis in addition to mycostatin to eliminate the bacterial component of the biofilm. (see below)

There are several methods that help prevent yeast from growing on the voice prosthesis:

• Reduce the consumption of sugars in food and drinks, brush your teeth well after consuming sugary food and/or drinks.
• Brush your teeth well after every meal and especially before going to sleep.
• Clean your dentures daily.
• Diabetic should maintain adequate blood sugar levels.
• Take antibiotics and corticosteroids only if they are needed.
• After using an oral suspension of an antifungal agent, wait for 30 minutes to let it work and then brush your teeth. This is because some of these suspensions contain sugar.
• Dip the voice prosthesis brush in a small amount of mycostatin suspension or vinegar and brush the inner voice prosthesis before going to sleep. (A homemade suspension can be made by dissolving a quarter of a mycostatin tablet in 3-5 cc water). This would leave some of the suspension inside the voice prosthesis  The unused  suspension should be discarded. Do not place too much mycostatin or vinegar in the prosthesis to prevent dripping into the trachea. Speaking a few words after placing the suspension will push it towards the inner part of the voice prosthesis.  
• Consume probiotics by eating active-culture yogurt and/or a probiotic preparation.
• Gently brush the tongue if it is coated with yeast (white plaques) 
• Replace the toothbrush after overcoming a yeast problem to prevent re colonizing  with yeasts
• Keep the prosthesis brush clean

Candida albicans as seen under the microscope